insertion (of IUCD)

Last edited 07/2019 and last reviewed 03/2021

• as a Cu-IUD is effective immediately after insertion it can be inserted at any time in the menstrual cycle if it is reasonably certain the woman is not pregnant (1)
  • NICE state with respect to fitting a copper IUCD; provided that it is reasonably certain that the woman is not pregnant, IUDs may be inserted: (2):
    • at any time during the menstrual cycle
    • immediately after first- or second-trimester abortion, or
    • at any time thereafter from 4 weeks post-partum, irrespective of the mode of delivery
      
      
• LNG-IUS insertion (1)
  • SPCs for Mirena and Jaydess state that the LNG-IUS can be inserted up to Day 7 of the menstrual cycle
    • no advice is given regarding avoidance of UPSI before insertion or use of additional contraception after insertion, and there is no information on starting the method at any other time in the cycle. Thus, the SPCs suggest that the LNG-IUS can be safely inserted as late as Day 7 with no risk of pregnancy from UPSI earlier in the cycle or after insertion
    • advice from the FSRH and the World Health Organization (WHO) is consistent with that of the SPCs, stating that the LNG-IUS can be inserted up to Day 7 without the need for additional contraception, and that if an LNG-IUS is inserted later in the cycle additional contraceptive precautions are required for 7 days
• STI risk assessment (history and examination) should be performed for all women considering an IUD (1)
  • a sexual history must be taken in order to identify women at risk of STI
  • risk factors include:
    • being sexually active and aged<25 years
    • having a new sexual partner in the last 3 months
    • having more than one sexual partner in the last year
    • having a regular sexual partner who has other sexual partners
    • a history of STIs
    • attending as a previous contact of STI
    • alcohol/substance abuse
  • an STI screen should be offered to all women who are identified as being at risk of STIs when requesting
    • if STI testing is indicated Chlamydia trachomatis testing should be performed as a minimum requirement. In most settings a single vulvovaginal or endocervical swab can be sent for combined C. trachomatis and Neisseria gonorrhoeae testing by nucleic acid amplification techniques
    • vulvovaginal swabs may be self-taken if preferred
    • urine specimens are no longer recommended for STI testing in women
    • syphilis and HIV testing should also be offered routinely
    • there is no indication to screen for other lower genital tract organisms in asymptomatic women considering IUC. If bacterial vaginosis or candidal infection is diagnosed or suspected the infection should be treated and the method inserted without delay
    • a high vaginal swab is not routinely indicated in women with vaginal discharge unless specific indications (see linked item)
      
      
  • in asymptomatic women attending for insertion of IUC there is no need to wait for STI screening results or to provide antibiotic prophylaxis providing the woman can be contacted and treated promptly in the event of a positive result
    • however antibiotic prophylaxis for chlamydia (and gonorrhoea if local prevalence or individual risk factors warrant) can be considered for women who require an emergency IUD and who are symptomatic or at high risk of STI (e.g. if their partner is known to be infected) (1)
      
      
• streptococcal bacteria and IUCD insertion (1)
  • in asymptomatic women routine screening for bacterial infection is not recommended prior to IUC insertion
    • however, cases of group A streptococcus (GAS) infection have been reported post-IUD insertion
      • cases are rare but can include life-threatening septicaemia, invasive GAS (e.g. necrotising fasciitis) and streptococcal toxic shock syndrome
      • it is important that women found to be infected with GAS in the vagina are treated and IUC insertion delayed
    • no need to delay treatment or treat asymptomatic women who have been identified as having Group B streptococci
      
      
• use of prophylactic for routine IUD insertion (1)
  • prophylactic antibiotics may be considered for women who are at increased risk of STI if an IUD is to be inserted prior to results of tests being available
  • prophylactic antibiotics are not routinely required for the insertion or removal of IUC even in women with conditions where the risk of infective endocarditis may be increased
    
    
• pulse rate should be measured and documented post-IUD insertion (1)
  • when bradycardia is associated with clinical signs and symptoms pallor, light-headedness, nausea) BP should also be measured and recorded
    
    
• IUC users should be informed about symptoms of ectopic pregnancy (1)
  • possibility of ectopic pregnancy should be considered in women with an intrauterine method who present with abdominal pain especially in connection with missed periods or if an amenorrhoeic woman starts bleeding. If a pregnancy test is positive, an ultrasound scan is urgently required to locate the pregnancy

Summary - Insertion of IUCD key facts:

• Copper IUCD (Cu-IUCD)

• Circumstance	Timing of Insertion	Additional contraceptive precautions required
  All circumstances	Any time in menstrual cycle if reasonably certain the woman is not pregnant or at risk of pregnancy (unless qualifies for use as EC)	No
  Postpartum (including post- Caesarean section and breastfeeding)	Any time after 4 weeks postpartum and it is reasonably certain the woman is not pregnant or at risk of pregnancy (unless qualifies for use as EC)	No
  Following abortion (all induced or spontaneous abortions < 24 weeks' gestation)	Post-surgical abortion IUC: ideally should be inserted at the end of the procedure Post-medical abortion IUC: can be fitted any time after completion of the second part of the abortion (i.e. passage of products of conception confirmed by clinical assessment and/or local protocols)	No
  Following administration of oral EC	Within the first 5 days (120 hours) following first UPSI in a cycle or within 5 days from the earliest estimated day of ovulation	No additional precautions required - if within the first 5 days (120 hours) following first UPSI in a cycle or within 5 days from the earliest estimated day of ovulation
  Following administration of oral EC	Outside of the above criteria Cu-IUD should not be inserted following administration of oral EC until pregnancy can be excluded by a pregnancy test no sooner than 3 weeks after the last episode of UPSI	Not applicable

• levonorgestrel intrauterine system (LNG-IUS)

• Circumstance	Timing of Insertion	Additional contraceptive precautions required
  All circumstances	Any time in menstrual cycle if reasonably certain the woman is not pregnant or at risk of pregnancy (outside terms of product licence after Day 7)	Yes, required for 7 days unless inserted in the first 7 days of the menstrual cycle
  Postpartum (including post- Caesarean section and breastfeeding)	Any time after 4 weeks postpartum and it is reasonably certain the woman is not pregnant or at risk of pregnancy (outside product licence which says 6 weeks)	Yes, required for 7 days unless inserted in the first 7 days of menstrual cycle or if fully meeting LAM criteria
  Following abortion (all induced or spontaneous abortions < 24 weeks' gestation)	Post-surgical abortion IUC: ideally should be inserted at the end of the procedure Post-medical abortion IUC: can be fitted any time after completion of the second part of the abortion (i.e. passage of products of conception confirmed by clinical assessment and/or local protocols)	If an LNG-IUS is fitted after Day 7 post-abortion, additional precautions are required for 7 days
  Following administration of oral EC	Should not be inserted following administration of oral EC until pregnancy can be excluded as above	Not applicable

Notes:

• Emergency contraception (EC) and insertion of a copper IUCD (1)
  • if a woman has had UPSI, a Cu-IUD can be inserted as a means of EC providing it is inserted before the process of implantation begins (i.e. within 120 hours of the first episode of UPSI in a cycle, or up to 5 days after the earliest estimated day of ovulation). It is not always possible to know when a woman has ovulated, particularly if she has been using hormonal contraceptives or taken EC
  • a Cu-IUD can be fitted in good faith to act as EC, providing appropriate steps have been taken to try and establish a woman's earliest estimated date of ovulation. The Cu- IUD should not be inserted if there is a risk of pregnancy outside these circumstances or where there is uncertainty about the earliest date of ovulation

Reference:

1. FSRH Guidance (April 2015) Intrauterine Contraception
2. NICE (September 2014). Long-acting reversible contraception (update)
3. Pulse (2001); 61 (37): 84.
4. BNF 7.3.4.